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- ↵⁎Reprint requests and correspondence:
Dr. John S. Rumsfeld, Denver VA Medical Center, Cardiology (111B), 1055 Clermont Street, Denver, Colorado 80220-3808
Reducing racial disparities is central to improving the quality of health care delivered in the U.S. (1). Nowhere has the focus on racial disparities been more intense than around cardiovascular procedures, driven by studies demonstrating that racial minorities are less likely to receive such procedures and may be at elevated risk for adverse outcomes compared with white patients (2–5). Nevertheless, studies of racial differences in outcome after cardiovascular procedures have yielded inconsistent results, leaving open questions about the magnitude of the problem as well as potential solutions.
In this issue of the Journal, Trivedi et al. (6) report the results of a study of racial differences in outcome after several cardiovascular procedures, specifically addressing whether hospital procedure volume might explain observed differences. Using a national administrative database of 719,679 hospitalizations, they found that African-American patients had significantly higher risk-adjusted in-hospital mortality for coronary artery bypass graft (CABG) surgery, elective abdominal aortic aneurysm repair, and carotid endarterectomy compared with white patients. Furthermore, minority patients were more likely to be treated at low-volume hospitals, and hospital volume had an overall association with in-hospital mortality. Despite this, there were no significant differences in racial disparity between the low- and high-volume hospitals. For example, the risk-adjusted mortality difference for CABG surgery between African-American and white patients was 0.4% in low-volume hospitals and 0.7% in high-volume hospitals. This study, therefore, documents the presence of racial disparities in outcome after cardiovascular procedures, but demonstrates that hospital procedure volume is not a mediator of these differences.
Hospital procedure volume has received national attention as a marker of hospital quality (7). Recently, however, concerns have been raised about the value of hospital procedure volume as a quality metric, especially for CABG surgery and percutaneous coronary intervention. Although multiple studies have found a general association between hospital procedure volume and mortality, the relationship tends to be modest and have a large variance (8,9). Thus, hospital procedure volume appears to be a poor discriminator of quality of care. Because racial equity is a central domain of quality of care, Trivedi et al. (6) add to the evidence challenging hospital volume as a quality metric by demonstrating that it does not explain racial differences in outcome after cardiovascular procedures.
If hospital procedure volume does not explain racial disparities in outcome after cardiovascular procedures, what does? The answer is not simple. However, there are several important considerations ranging from access to care, to referral for cardiovascular procedures, to quality issues related to care delivery at the hospitals where procedures are performed. Because minorities are more likely to have low socioeconomic status and be uninsured, improved access to care may be critical for reducing racial disparities in care and outcome for minority populations overall (1,10). Moreover, even with access to cardiovascular procedures, there is evidence that they are underused in minorities (11). Underuse of indicated procedures is intrinsically associated with worse outcomes (11), and may lead to worse after-procedure outcomes for minorities if they are referred later in disease course or under less elective conditions. Overuse of cardiovascular procedures in whites (including more low-risk elective cases) may play a role as well (11), highlighting the need for appropriateness criteria in quality metrics.
Finally, quality deficiencies within the hospitals where minorities undergo cardiovascular procedures may contribute to worse after-procedure outcomes. In general, racial minorities are more likely to receive care from hospitals with lower rates of evidence-based medical therapies (1,12). More specifically, there is evidence that racial disparity in outcomes after CABG surgery increases over time after the operation, suggesting that racial minorities receive less secondary prevention following surgery (13). Furthermore, data from New York indicate that racial minorities are more likely to be treated by surgeons with higher risk-adjusted mortality rates compared with white patients (14).
Taken together, this evidence points to improved access to high-quality care for minorities as a key to eliminating racial disparities. There may be other contributors to racial differences in outcomes after cardiovascular procedures (e.g., inherent biological differences in disease manifestation), but until or unless specific mediators and proven interventions to obviate these differences are found, the pursuit of high-quality care is the best avenue. There are two potential approaches to achieve higher quality care: treat minority patients at higher quality centers (“between-hospitals” solutions) or improve the quality of care at the hospitals where they are currently being treated (“within-hospital” solutions).
One example of a between-hospitals approach is regionalization of cardiac procedures or concentration of procedures within cardiovascular centers of excellence. Such efforts may improve access to cardiovascular procedures and high-quality providers for minority patients, although there is uncertainty about the costs and benefits (15). Racial minorities, who are more likely to be treated at hospitals that would be excluded from regional networks and are subject to higher barriers to access in general, may not realize the advantages of regionalization. Importantly, as Trivedi et al. (6) demonstrate, basing a regionalization policy on hospital procedure volume would seemingly do little to alleviate racial disparities in outcome. If regionalization is to be implemented, centers should be chosen on the basis of measures such as the 20 non–volume-based standards for cardiac surgery delineated by the National Quality Forum (16), and the impact on minorities should be explicitly considered and evaluated.
Within-hospital solutions, namely quality improvement efforts, are less controversial. Participation in procedure registries such as the Society of Thoracic Surgeons database and the American College of Cardiology National Cardiovascular Data Registry enable benchmarking of processes of care and outcomes along with detailed risk adjustment. There is emerging evidence from initiatives such as the American Heart Association’s Get With the Guidelines programs that participation can reduce racial gaps in quality of care (17). In addition, the growing field of medical simulation, both for individual skill development and team training, holds promise for reducing complications and improving patient outcomes after cardiovascular procedures (18). For these initiatives to have an impact on racial disparities, however, hospitals serving minority populations, which may have more stringent resource constraints, need to adopt them. The effort required to make this happen will not be trivial and may require external assistance for financing and implementation.
In conclusion, the study by Trivedi et al. (6) provides evidence of racial differences in outcome after cardiovascular procedures and points us away from solutions that are tied to hospital procedure volume. More promising are strategies that focus on improving the quality of care within hospitals. Participation in established national registries to facilitate benchmarking of care, coupled with new technologies such as medical simulation training, holds great promise for improving quality of care and outcomes after cardiovascular procedures for the U.S. as a whole. It is hoped that these efforts will close the racial gap in quality of care and outcomes, but will require special effort and support in hospitals that treat underserved populations. Nevertheless, as the quality improvement era moves forward, we should leave hospital procedure volume behind as too crude a quality marker to discriminate adequately between hospitals and as a dead end in the quest to eliminate racial disparities.
↵⁎ Editorials published in the Journal of the American College of Cardiologyreflect the views of the authors and do not necessarily represent the views of JACCor the American College of Cardiology.
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